1366529372 NPI number — BRANDON LEWIS POLK DDS

Table of content: BRANDON LEWIS POLK DDS (NPI 1366529372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366529372 NPI number — BRANDON LEWIS POLK DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLK
Provider First Name:
BRANDON
Provider Middle Name:
LEWIS
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366529372
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/16/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6812 VALLEY LAKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27612-1731
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-847-7339
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4400 FALLS OF THE NEUSE RD
Provider Second Line Business Practice Location Address:
STE 200
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27609
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-954-8570
Provider Business Practice Location Address Fax Number:
919-954-8567
Provider Enumeration Date:
11/01/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  8021 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5901041 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9021T . This is a "BLUE CROSS BLUE SHIELD NC" identifier . This identifiers is of the category "OTHER".